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Aircraft Accident Report and Executive Summary

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Aircraft Accident Report and Executive Summary Section/division Accident and Incident Investigation Division Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY Reference: CA18/2/3/9505 Aircraft registration ZS-DKS Date of accident 7 December 2015 Time of accident 0857Z Type of aircraft Eclipse EA500 (Aeroplane) Type of operation Private (Part 91) Pilot-in-command licence type Private Age 57 Licence valid Yes Pilot-in-command flying Total hours 2 977.0 Hours on type 506.15 experience Last point of departure Lanseria International Airport (FALA), Gauteng Next point of intended landing Cape Town International Airport (FACT), Western Cape Location of the accident site with reference to easily defined geographical points (GPS readings if possible) On the farm Spioenkop, Overberg district, (GPS position: 34°10.31’ South 020°08.15’ East) Meteorological Surface wind: 160º/5kt, Temperature: 24ºC, CAVOK information Number of people on 1 + 0 No. of people injured 0 No. of people killed 1 board Synopsis The aircraft had taken off on a private flight with the pilot being the sole occupant on board. The pilot had filed an IFR flight plan and had informed air traffic control (ATC) at FALA that the aircraft had a fuel endurance of 4 hours and his estimated flying time to FACT was approximately 2 hours and 30 minutes. After take-off the aircraft climbed to its cruising altitude of 36 000 feet (FL360) as was seen on the radar recordings. The pilot maintained communication with ATC until overhead Kimberley. Shortly thereafter the aircraft was observed to change course, turning slightly left before the town of Douglas. The aircraft remained at FL360 and was observed to fly south towards the waypoint OKTED, which was a substantial distance to the east of FACT. FACT could not get communication with the aircraft and the aeronautical rescue co-ordination centre (ARCC) was advised of the situation. The aircraft was kept under constant radar surveillance. The ARCC requested assistance from the South African Air Force (SAAF) and a Gripen (military jet) from Air Force Base Overberg (FAOB) was dispatched to intercept the aircraft. The pilot of the Gripen intercepted the aircraft approximately 3 minutes before it impacted the terrain. The Gripen pilot was unable to get close enough to the aircraft as it was flying very erratically, and he could therefore not see whether the pilot was conscious or not. The aircraft was observed entering a left spiral and continue spiralling down until it impacted the ground. The pilot was fatally injured and the aircraft was destroyed during the impact sequence. The investigation revealed no anomalies on the part of the aircraft and all damage was attributed to the impact with the ground. The fatal injuries sustained by the pilot made it imposible to determine if the pilot was incapasitated or not. Probable cause It was observed that the aircraft performed a series of unexplainable as well as erratic flying maneuvres, which resulted in a loss of control and the aircraft to enter into a spiral dive, which was observed by the Gripen pilot before colliding with the ground. SRP date 11 September 2018 Release date 27 September 2018 CA 12-12a 01 FEBRUARY 2017 Page 1 of 58 Section/division Accident and Incident Investigation Division Form Number: CA 12-12a AIRCRAFT ACCIDENT REPORT Name of Owner : Dixco Transport (Pty) Ltd Name of Operator : Private (Part 91) Manufacturer : Eclipse Aerospace Model : EA500 Nationality : South African Registration marks : ZS-DKS Place : On the farm Spioenkop, Overberg district Date : 7 December 2015 Time : 0857Z All times given in this report are Coordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. Purpose of the investigation: In terms of Regulation 12.03.1 of the Civil Aviation Regulations (2011) the purpose of investigation of an aircraft accident or incident is to determine, in terms of the provisions of this Part, the facts of an accident or incident in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents, and not to establish blame or liability. Disclaimer: This report is produced without prejudice to the rights of the CAA, which are reserved. 1. FACTUAL INFORMATION 1.1 History of flight 1.1.1 On Sunday afternoon, 6 December 2015 at 1345Z, the aircraft ZS-DKS took off from Cape Town International Airport (FACT) on a private flight to Kuruman Airport (FAKU). On board the aircraft was the pilot, who was also the owner of the aircraft, accompanied by three passengers. In an interview, one of the passengers on this flight indicated that it was an uneventful flight. The duration of the flight was approximately 2 hours and they landed at FAKU between 1530Z and 1545Z. The pilot owned a business in Kuruman and the passengers were returning home. The aircraft was parked at the airport overnight. The intention of the pilot, as the CA 12-12a 07 FEBRUARY 2017 Page 2 of 58 passenger understood it, was to fly back to Cape Town the following day. 1.1.2 On Monday morning, 7 December 2015 the pilot, being the sole occupant on board the aircraft, took off from FAKU and flew to Lanseria International Airport (FALA) in Gauteng. Available evidence indicates that he did not experience any defects or system malfunction with the aircraft during the flight. The flight time to FALA was approximately 45 minutes and the aircraft landed at FALA at 0445Z. 1.1.3 After landing the pilot taxied towards the hangars on the southern side of the aerodrome. After the aircraft was parked, it was refuelled and 750 litres of Jet A1 was uplifted. The pilot then spent some time on the ground, where he met up with an associate. It was also during this period that he handed a suitcase as well as a briefcase to the secretary of the person he visited. He indicated that his wife would come and pick it up at some stage and gave her his wife’s name and contact number. He then returned to the aircraft to prepare for the flight to FACT. 1.1.4 An IFR flight plan was filed for the flight, which indicated the route as follows: FALA/N0340F360 LIV DCT XAGEN UZ31 XALVA UQ23 CSV UZ26 ERDAS DCT FACT. George Aerodrome (FAGG) was reflected on the flight plan as his alternate aerodrome. Also, under the supplementary information the estimated departure time from FALA was entered as 0500Z, with an endurance of 3 hours and 30 minutes, and search and rescue was entered as normal (SARNML). The aircraft departed FALA at 0621Z from runway 07, and after becoming airborne the aircraft was observed on radar to turn left on track as per the ATC clearance. 1.1.5 According to available information the pilot maintained radio contact with air traffic control at FALA on the tower frequency 124,0 MHz. The after-departure clearance as issued by the ATC required the pilot to contact Johannesburg radar on 123,7 MHz. when passing through 6500 ft. According to radar information at 06:48:21, with the aircraft positioned overhead Klerksdorp, it reached its cruising altitude of 36 000 feet (FL360). It remained on track and was observed to start changing heading at 07:20:32 just before the town of Douglas in the Northern Cape by turning slightly left while remaining at its cruise altitude of FL360. The pilot complied with ATC instructions, and when he reached the hand-over reporting point established radio communication with Johannesburg flight information region (FIR) Central on 120,3 MHz. He then continued on Upper Airway UZ31 as per the flight plan while maintaining FL360. It was noted that the last communication between the pilot and ATC was when the aircraft was near the city of Kimberley. CA 12-12a 07 FEBRUARY 2017 Page 3 of 58 1.1.6 The mandatory occurrence report (MOR) with reference number CA-87-2015 indicated that the aircraft entered the FACA FIR (Area Control Centre) airspace without any communication from the pilot. However, throughout Johannesburg Area (FAJA) flight information region FIR continually attempted to re-establish communication with the pilot of ZS-DKS. A decision was then made to notify the aeronautical rescue control centre (ARCC) of the situation. Due to the nature of the situation, an INCERFA was declared. From this point onwards the aircraft was under permanent surveillance while being tracked on radar. 1.1.7 Once the aircraft was observed to change heading it was flying south towards the OKTED waypoint, which was a substantial distance to the east of FACT (heading of 133° and a distance of 50 nm). The aircraft was observed flying overhead the town of Robertson at 08:32:45 and the ESRUK waypoint near the town of McGregor at 08:34:44, maintaining FL360 en route to the OKTED waypoint, which was some distance to the south. At 08:37:04 the aircraft was observed to commence with a right turn, during which the height of the aircraft varied by 2 000 feet, remaining between FL350 and FL370. The aircraft completed a 360° turn to the right and immediately commenced with a second right-hand turn. 1.1.8 After it had completed the second 360° turn, it was observed to fly in an easterly direction for a brief period, during which the aircraft was observed to have climbed to an altitude of FL376, after which it descended and again entered into a right-hand turn at 08:44:38 at an altitude of FL330 and a speed of 456 knots.
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